Individual at Rye Hill

The death of a man at
HMP Rye Hill in August 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2005
This is the report of an investigation into the circumstances of the death of a
man at HMP Rye Hill in August 2004. The man’s primary cause of death was
ischaemic heart disease (disease arising from an inadequate oxygen supply
to the heart). The man was serving an eight-year sentence at the time of his
death.
The investigation was carried out on my behalf by one of my investigators. A
clinical review was carried out by a qualified nurse who also works for my
office.
We would like to extend our condolences to the man’s family for their loss. We
would also like to thank the Director of Rye Hill, and the other members of his
staff for their help.
This report commends Healthcare nursing staff for their professional care and
treatment of the man and for the compassion with which they delivered that
care.
Stephen Shaw CBE April 2005
Prisons and Probation Ombudsman
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Index
Summary
Investigation Process
HMP Rye Hill
The Events Leading up to the Man’s Death
After the Man’s Death
Level of Compliance
Findings and Conclusions
Good Practice
Recommendations
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Summary
The man was born in 1931 and was 73 years-old when he died in August 2004
from ischaemic heart disease. At the time of his death, he had served four
years of an eight-year sentence. Following his conviction, the man had first
gone to HMP Bullingdon, before being transferred to HMP Rye Hill in April
2001.
On arriving at HMP Rye Hill in April 2001, the man had a routine medical
examination. The doctor noted that the man’s clinical history included:
diabetes, a myocardial infarction (heart attack) in 1981, a cardiovascular
accident (stroke), and an operation on his carotid artery (the carotid artery is
located in the front of the neck and carries blood from the heart to the brain).
Despite his clinical history, the man had no significant health problems over
the course of the following two and a half years. Entries in his medical records
for this period relate largely to the management of his diabetes and secondary
conditions associated with that disease. Several entries in the record suggest
that the man was feeling well for much of his time at Rye Hill.
The first documented instance of deterioration in the man’s health was an
entry in his medical record on 9 December 2003 when he reported that he was
spitting blood. His health was consistently poor from that time onwards. The
man had several admissions to outside hospital, one stay lasting almost two
months, and when back at Rye Hill he spent most of his time in the Healthcare
unit.
A clinical review of the man’s treatment found that his death was not
connected to the fact that he was in prison, or to the level of care that he
received there.
This report commends Healthcare nursing staff while making
recommendations about record keeping practices and standards.
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Investigation Process
My practice in cases of apparent deaths from natural causes is to conduct an
initial review to determine the extent of investigation required.
My investigator visited Rye Hill on 18 August 2004 when he visited the
Healthcare unit where the man was nursed and where he died. My
investigator spoke informally with a number of staff to outline the facts relating
to the man’s care and his subsequent death. My investigator was given
access to all of his prison records, including the medical records.
My investigator also met a member of the Independent Monitoring Board
(IMB). The IMB member told my investigator that he had met the man when
he was a patient in the prison’s Healthcare unit. The man had praised the
Healthcare nurses for their care and commitment, adding that the care he
received in the Healthcare unit was better than the care he had received in
outside hospital. Although the IMB member had no matters of concern to
raise with my investigator about the man’s care and treatment, he did raise
two issues of general concern. The first issue was his view that staff at Rye
Hill were generally young and lacking in experience. The second issue was
that staffing levels are such that there are sometimes no staff available to
accompany prisoners to external hospital appointments, resulting in
cancellation of the appointment.
My investigator spoke with a prison chaplain who had visited the man in
Healthcare the week before his death. During their conversation the man had
once again complimented the Healthcare nurses. Several weeks later, my
investigator made a further, unrelated, visit to Rye Hill. On that day, the
investigator met a second IMB member who, like others, mentioned the man’s
praise of Healthcare staff.
The investigator wrote to the man’s son and next-of-kin to ask whether he had
any concerns about his father’s care and treatment. No response has been
received to that enquiry.
A trained nurse carried out a clinical review of the man’s care and treatment.
No formal interviews with staff were conducted, although my investigator
spoke informally to several staff. This report is based upon those discussions
and upon a review of relevant paperwork, including the man’s clinical records.
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HMP Rye Hill
Rye Hill was opened in early 2001 as a purpose built category B training
prison. It has a 660-bed capacity, predominantly made up of single cells.
Rye Hill is a privately managed prison run by Global Solutions Ltd.
Global Solutions Ltd’s stated aims include the creation of a constructive prison
regime through the provision of education, work and other programmes to best
prepare people for re-integration into mainstream society.
The prison regime is based on a minimum of 35 hours per week purposeful
activity including work, training and education (including physical education),
and offending behaviour programmes, all of which are linked to a system of
earned incentives and privileges.
Healthcare services at Rye Hill are provided by Primecare Forensic Medical, which is
a private healthcare provider. The Healthcare unit is staffed 24 hours per day by
qualified nurses and healthcare assistants who are supported by visiting specialists,
including doctors, dentists and psychiatrists. The Healthcare unit has eight in-patient
beds.
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The Events Leading up to the Man’s Death
The man was received at Rye Hill in April 2001, upon his transfer there from
HMP Bullingdon. At initial medical assessment on 21 April 2001, the
examining doctor noted that the man’s past medical history included a heart
attack in 1981, a stroke, diabetes, and a carotid embolectomy (surgical
removal of an arterial blood clot). Despite this history, the doctor noted that
the man looked reasonably well.
Over the course of the following two and a half years, the man had regular
clinical reviews in the prison’s Healthcare unit, which included appointments
with opticians, dentists and chiropodists. Periodic notes were made in his
clinical record that the man was feeling well.
The first indication of a decline in the man’s health was noted on 9 December
2003, when an entry was made in his clinical record that he was complaining
of a sore throat, cough, and was spitting blood. It was also recorded that he
was short of breath on exertion. The man had no further Healthcare
consultations that month, however on 13 January 2004 he again visited
Healthcare to mention that he observed a speck of blood in his phlegm. One
week later, the man returned to Healthcare to report that he was again
coughing blood and so sputum samples were taken for testing. On the
following day, 21 January, he was referred to outside hospital for tests. The
man was admitted to hospital where he was diagnosed with bilateral
pulmonary embolism that was treated with Warfarin. The man returned to Rye
Hill on 3 February.
The man was referred to hospital again on 7 February when he complained to
Healthcare of being short of breath and of feeling severe pain. He remained in
hospital for the night of 7 February before returning to Rye Hill. The man had
further and longer outside hospital admissions: from 19 February to 3 March;
from 14 April to 8 June; and, finally, from 17 June to 21 June.
It is clear from the clinical review that the man’s health was deteriorating, and
for most of the time during his final months at Rye Hill he was an in-patient in
the prison’s Healthcare unit. To assist in his care, the prison obtained from the
local NHS hospital a specialist pressure-relieving mattress. In an internal
prison memo dated 16 July, a Healthcare doctor wrote: ‘This man is in
extremely poor health. He has long standing diabetes and ischaemic heart
disease, both of which conditions are insidiously progressive. He is now in
end stage cardiac failure and has chronic renal failure …’
On 3 August, an entry was made in the man’s clinical record that he had told a
Healthcare nurse that be believed he had little time left as his heart was weak.
An entry in the clinical record made the following day referred to the man as
appearing very frail and not as chatty as usual. No significant entries were
made in the man’s clinical record during the next few days.
A few days later the head of Healthcare, a trained nurse, arrived at work at
7.30am. She said good morning to the man before attending two health
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clinics. The clinics had finished by 10am at which time the head of Healthcare
took breakfast to the man. She moved him from bed and on to a wheelchair
and they chatted briefly. Another Healthcare nurse checked the man at about
10.50am, at which time he was watching television. A prison officer would
also have carried out a check of all prisoners in Healthcare that morning. Just
after midday, the head of Healthcare went to the man’s room to ask him what
he wanted for lunch. She found him slumped in his wheelchair and on
examination found that he was dead. She told my investigator that although
the man was terminally ill, he was comparatively well that morning and so she
was surprised that he then died so suddenly.
After the Man’s Death
The Duty Director telephoned the man’s son to inform him about his father’s
death. In the case of deaths through natural causes, Rye Hill’s policy is to
notify the next-of-kin by telephone and to make that call without delay to avoid
the possibility of the next-of-kin hearing the news from other sources. Later on
that day the Director at Rye Hill also telephoned the man’s son and offered
him the opportunity of a meeting.
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Level of Compliance
Standards of health care in prison are intended to mirror those available in the
outside community. This aspect of the man’s care is described in the
independent clinical review, which concludes that there appears to be no
difference in the care that the man received at Rye Hill than if he had not been
in custody. The clinical review commends nursing staff at Rye Hill for their
liaison with the outside hospital. It is also evident that the man was highly
appreciative of the commitment of the Healthcare nurses, as was
independently reported to my investigator by two IMB members and a prison
chaplain.
The post-incident response was fully compliant with Prison Service instructions
on managing a death in custody.
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Findings and Conclusions
The man was approaching his 70th birthday when he first arrived at Rye Hill in
April 2001. His past medical history included a heart attack, a stroke, and
surgery for removal of an arterial blood clot. Despite this history, the man’s
clinical records over the following two and a half years contain reference only
to the ongoing monitoring of his health with no concerns being noted.
The first significant event occurred in December 2003 when the man reported
a sore throat and that he was spitting blood. From that time onwards, his
clinical records show that the man was becoming more and more unwell.
Over the course of the following eight months, the man was referred to
outside hospital on six different occasions – on one occasion he went out and
came back on the same day, otherwise he remained in outside hospital for
periods of time ranging from two days to almost two months. While back at
Rye Hill, the man mainly stayed in Healthcare and he praised the Healthcare
nurses when speaking to IMB members and a prison chaplain.
On 16 July, a Healthcare doctor described the man as being in end stage
cardiac failure, and he died in the late morning in August. He was seen by
nursing staff several times that morning – the last time just before 11am – but
there had been nothing about his condition to cause staff any concern.
However, when the head of Healthcare went to see the man just after midday,
she found that he had died.
The clinical review found that the man was well cared for in Rye Hill with the
health care he received there being probably at least as good as it would have
been outside in the community.
However, my reviewer has commented in her clinical report on a number of
areas where record keeping might have been improved. She advised that
best practice would be achieved by keeping distinct nursing records, medical
records, and records relating to the management of chronic diseases. She
has also identified that the man’s nursing notes report that he suffered three
falls during the last month of his life, but there was only one accident report for
a fall in his records. These areas form the recommendations of this report.
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Good Practice
In her review of the man’s clinical care my reviewer commended the good
daily liaison between the prison’s Healthcare nursing staff and the local
hospital during his admissions to outside hospital. This liaison, she believed,
was commendable both for, and of its self, and for the high standard of
contemporaneous entries in the man’s records. I also note a reference to two
instances when Healthcare staff ensured that the man’s discharge from
outside hospital occurred only once sufficient preparation had been made for
his safe management back at Rye Hill.
My reviewer also commended the involvement of local district nurses in the
man’s care.
I am happy to endorse all of these commendations. I also wish to add my
own commendation of the Healthcare nurses who obviously treated the man
with care and compassion during what were clearly recognised to be the final
months of his life.
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Recommendations
The clinical review found that the man received appropriate care and
treatment while at Rye Hill, it also identified areas where record keeping could
be improved. My recommendations, deriving from the clinical review, are as
follows:
Local Recommendation: 1. A clear distinction between nursing records
and the continuous medical record should be consistently maintained.
Local Recommendation: 2. The Healthcare unit should consider the
creation within the clinical record of separate sections for chronic disease
management.
Local Recommendation: 3. The system for reporting and following up
accidents, including falls, should be reviewed in accordance with health
and safety regulations.
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